Provider Demographics
NPI:1700992971
Name:JACK D. CLOSE AND ASSOCIATES
Entity Type:Organization
Organization Name:JACK D. CLOSE AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CLOSE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MAPT,FAPTA
Authorized Official - Phone:702-731-6873
Mailing Address - Street 1:3650 S EASTERN AVE
Mailing Address - Street 2:#100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-3379
Mailing Address - Country:US
Mailing Address - Phone:702-731-6873
Mailing Address - Fax:702-731-2565
Practice Address - Street 1:7373 PEAK DR
Practice Address - Street 2:#230
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9003
Practice Address - Country:US
Practice Address - Phone:702-215-4353
Practice Address - Fax:702-215-4356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV57225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV32430Medicare ID - Type Unspecified
NV100503Medicare ID - Type Unspecified
NVV32404Medicare ID - Type Unspecified
NV103684Medicare ID - Type Unspecified